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Job Details

Quality Analyst

Category: Registered Nurse
10 Beacon St, Somerville, MA

Department: Surgery Admin
Job Type: Full Time
Job Class: Non-Union
Work Shift: Day/Evening with Variable Start Time
Work Days: 8-4:30
Hours/Week: 40
Date Posted: 08/20/2019
Requisition Number: hrq-86529

Job Details

  • Specific Job Responsibilities and Capabilities:

    1. Data Collection and Reporting

    a. Identifies surgical patients for inclusion in the program through the application of program inclusion/exclusion criteria and protocols.

    b. Collects preoperative, operative, and postoperative data components for the program through the effective utilization of the hospital medical record systems.

    c. Completes an organized medical record review and data abstraction as required for CHA reporting. Is flexible with work hours in order meet deadlines and provide maximum abstraction productivity.

    d. Attends weekly Morbidity & Mortality conferences to ensure reliable data collection of postoperative occurrences.

    e. Demonstrates applicability of the methodology and the reliability of definitions utilized by reviewers within the program through Inter-Rater Reliability (IRR) testing.

    f. Researches, verifies and validates medical record documentation, including review of tests and reports, to record and report accurate information to external sources. Maximally utilizes all CHA data sources including hospital medical record, Meditech, and EPIC.

    g. Identifies streamlining and process improvement opportunities in the data collection process.

    h. Reviews data reports in order to identify inconsistencies. Communicates discrepancies/concerns to Senior Director and/or program manager

    i. Demonstrates appropriate utilization of resources necessary to obtain valid, reliable data for entry into the program.

    j. Utilizes all necessary software applications for data collection and analysis.

    k. Responsible for the accurate and timely entry of data into the NSQIP program's database and meets the caseload accrual requirement protocol.

    l. Reviews weekly site accrual report on the database and responds to accrual report alerts.

    m. Recommend corrective action to maintain integrity of coding and medical record documentation to ensure compliance.

    n. Reviews protocols for compliance with established databases, laws and regulations, policies and procedures.

    2. Works Effectively with Patients, Families, and Staff

    a. Establishes effective working relationships with members of the hospital community, especially staff in the Surgery, Medicine, Nursing, Medical Records and the Information Systems Departments whose support is necessary for the management and success of the program.

    b. Contacts patients and/or families via telephone and/or written communications postoperatively for identifying possible occurrences associated with surgical procedures performed at the hospital.

    c. Serves as an educational resource on the ACS NSQIP for internal and external audiences by developing educational material and delivering presentations.

    d. Works collaboratively to provide information internally and externally to appropriate departments as needed.

    3. ACS NSQIP Participation

    a. Successfully complete the ACS NSQIP SCR Training/Certification Program.

    b. Participates in program teleconferences

    c. Attends ACS NSQIP National Conference

    4. Other responsibilities

    a. Meets monthly with Chief of Surgery to review data collection and feedback from NSQIP and other items related to CHA involvement in NSQIP.

    b. Remains current regarding changes in regulatory requirements as related to pertinent data collection

    c. Performs other duties as needed and/or requested in order to enhance and maximize departmental resources.


    Education/Training: Bachelor's degree in Business Administration, Health Care or related field. Unless certification, licensure or registration is required, an equivalent combination of education and experience which provides proficiency in the areas of responsibility listed in this description may be substituted for the above requirements. Proficiency in computer applications is required (spreadsheets, databases, etc.)

    Licensure/Certification: Health care related certification such as RN, LPN, coding certification a significant plus. Knowledge of medical terminology and coding is required.

    Work Experience: 3-5 years in a hospital or other health care environment is required.


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